By Jeanie Davis

COVID-19 has spurred myriad changes in hospitals as providers scrambled to adapt to the new normal. That includes new and creative ways to connect and support patients, says Bonnie Geld, MSW, president and chief executive officer of the Center for Case Management.

Virtual patient care and digital outreach, now more readily available to patients, are among the new models that quickly emerged, says Geld. She also sees renewed emphasis on case managers, social workers, and utilization review in patient care — in coordinating care, supporting patients in the management of chronic illness and post-hospital care, and advocacy and interventions in social determinants of health.

Geld indicates these essential roles can be handled remotely. “We learned a lot during COVID-19 about the critical importance of case management,” Geld explains. “We learned how flexible the role has to be to meet the needs of our patients. But at a time when only the provider can be in the hospital room in some hospitals, the case manager has not been at the bedside.”

Many case managers have been working remotely, especially those in outpatient and ambulatory care centers, Geld adds. “Case managers in hospitals have had limited time at bedside with the patient, and only phone calls with family members. Utilization review has also been handled remotely.”

Yet those roles have been performed effectively, she adds. Teamwork was essential in this paradigm shift. “The need for collaboration has been at an all-time high.”

Adapting the Case Manager’s Skill Set

Case managers have become savvy using software to connect hospital care with post-acute care, Geld points out.

“There have been a lot of challenges in discharge planning to post-acute care due to semiprivate rooms and concern about disease transmission,” she explains. “With the high volume in these facilities, it’s been especially challenging.”

Working out the logistics, “case managers have used their ability to collaborate and predict which patients may need post-acute care so they can make plans very early for transition,” Geld says.

Social workers also have proven effective in assisting patients with emotional and mental health issues. “We learned that patient isolation has significant emotional consequences for the patient’s recovery and the family’s coping,” Geld explains. “The impact of a social worker shines in helping with emotional and mental health aspects of COVID, whether it’s the patient or the family. Social workers were very effective in helping with patients’ and families’ anxieties.”

Moving Forward with Medicaid

As patient volumes return to hospitals, they are challenged again with capacity, says Geld. “Now that hospitals have started doing elective surgeries, they will need a strong entry point case management resource. If hospitals haven’t planned their emergency room case management, they will be overwhelmed with COVID-19 cases, flu, and kids’ respiratory syncytial virus infections in the fall.”

As hospitals prepare for the return of preauthorizations and three-day requirements, she notes “it all is going to come back. It’s going to be interesting to see how many patients may not have met certain conditions for authorization pre-COVID. We’re going to have to support these efforts. All these things make the case manager’s mission critical.”

Geld sees great need for case managers in helping uninsured patients find the help they need. “For those uninsured and on Medicaid, they’re going to have a huge impact — especially on children’s hospitals,” she says.

A large percentage of pediatric hospital patients are on Medicaid, and that likely will increase. With people out of work, getting their kids on Medicaid will be essential, Geld says. “The need for case managers will be essential in helping them. It takes a lot of advocacy with Medicaid or MediCal [California’s Medicaid program] to get access to resources they need. The time and attention of both the social worker and case manager are very important.”

Hospital emergency departments will see more adult Medicaid patients, and patients with no insurance at all, especially if COVID-19 is considered a pre-existing condition, says Geld.

“It’s hard to know how insurance companies will handle it,” she says. “This demonstrates a need for stronger utilization review to get on top of payer requirements, and for case managers and social workers to advocate for resources.”

This role as advocate helps children and adults move through the system in a timely manner, which will help control volume and length of stay in the hospital, Geld adds. “Some Medicaid patients come in sicker because they’ve avoided the medical system. We need to see what we can do collectively for these patients at our doorstep.”

Social determinants of health are integral to this scenario, she adds. “COVID-19 has resulted in long food lines, and food insecurity is a major social determinant of health. People don’t have appropriate nutrition, and that is critical for people with chronic illness — yet it’s more expensive than snack food. We’re seeing long lines at food banks and more on SNAP [Supplemental Nutrition Assistance Program].”

Education and teaching tools are important, Geld says. “Health literacy is critical. We come across patients who don’t understand the impact of COVID-19, and some who remain skeptical about taking precautions. It takes a lot more education with these patients, as well as point-of-contact tracing.”

Also, when working with a recovering COVID-19 patient, case managers should help them understand what their recovery will involve, whether their family was exposed or is at high risk, and help them understand safety issues, she adds.

“The case manager can connect all the dots; they’ve always been responsible for care coordination,” says Geld. “We have to make sure all providers and the patient are on the same page. The fact that we have remote and bedside providers, remote families — communication is essential.”

The Center for Case Management is designing remote case management partnerships involving telehealth. “That will be very significant in the future,” Geld says. “Some patients are good with the phone; others like to see their electronic medical record online. We have to really understand how the patient and family access information best so we can best communicate with them.”

Mentoring Future Case Managers

It is time to nurture and encourage young case managers early in their career paths, says Audrey Sefakis, BSN, RN, CCM, case manager with Tuft Health Plan. “My daughter graduated from nursing school this year, and case management was small blurb in one chapter,” she says.

Sefakis believes nurses should learn about case management earlier in their training. “It’s a career opportunity they should consider, in addition to getting their clinical background. With so many nurses retiring, we need new case managers coming into the field,” she explains.

She advises academic nursing and social work programs to add case management as a topic in their care coordination and/or healthcare financing curricula. Sefakis also encourages professional organizations to create opportunities for proactive outreach. Conferences, educational institutions, and employer settings are perfect venues to connect with prospects. Sending enthusiastic speakers to schools, universities, and career fairs is possible with little planning.

Summer internships and mentoring should be possible in clinical settings, Sefakis adds. Shadowing a case manager, completing department research, participating in projects, conducting time studies, and performing administrative duties all present good assignments for an intern.

“Offering these experiences also allows organizations to network and recruit new talent,” she says. “An internship presents the opportunity to establish a one-on-one relationship between an experienced case manager and someone considering such a career path. The intern-preceptor relationship is extremely important, and warrants careful planning and execution to ensure success.”